The Oxfordshire Clinical Commissioning Group (CCG) in partnership with consultant Neurologists at the Oxford University Hospitals NHS Trust developed a headache pathway that would address the following NICE guidance:
NICE quality standards (QS42):
- Headache type classified as part of the diagnosis.
- Information provision on the risk of medication overuse headache
- Not referring for imaging if patients do not have signs of symptoms of secondary headache
- Advise on combination therapy with a triptan and either a non-steroidal anti-inflammatory drug (NSAID) or paracetamol.
- Raising public and professional awareness of primary headache disorders.
NICE CG150 Key Priorities:
Priorities summarised as follows:
- Accurate clinical diagnosis of primary headaches
- Be alert for medication overuse headache
- Do not image solely for reassurance
- Recognise and validate the patients suffering and provide explanations and reassurance, with evidence-based management options
Aims and objectives
Aim and objectives: What were you trying to achieve? How do the aims and objectives relate to NICE guidance / Quality Standards? (2500 characters maximum, including spaces)
Headache accounts for approximately 1 in 3 referrals to neurology outpatients department (OPD) in Oxfordshire. Most of those headaches are primary headache disorders such as migraine, or medication overuse headache. Once diagnosed, these can be managed in primary care without the need to escalate into expensive hospital clinics. The presence of these disorders within the OPD over-burdens the workforce and delays access for patients with other Neurological conditions, resulting in:
- delayed in the diagnosis and appropriate treatment advice for primary headache disorders (QS42.1&4, CG150)
- increased risk of medication overuse headache (QS42.2)
- a spill-over into unplanned presentations to the emergency department, also increasing the risk of inappropriate imaging (QS42.3)
It was felt that, rather than all referrals being seen in the OPD, they might more appropriately be triaged to one of the following services:
- Written advice back to referrer without seeing the patient (10%): For referrals where the headache is clearly a primary headache (such as migraine).
- Imaging without appointment (6%). Imaging (e.g. MRI Head) is organised without secondary care seeing the patient. Offered when the diagnosis is likely to be primary headache but there is sufficient clinical cause according to CG150 guidance to warrant imaging. If normal, the headache can be managed by the GP with written reassurance and advice from the headache specialist.
- Community Headache Clinic (50%): For referrals where the diagnosis is likely to be a primary headache or medication overuse headache, but the patient needs more support than the referrer can give. It would be run by a GP with a special interest in headache at a community location easier for patients to access and closer to home.
- General Neurology OPD Appointment (18%). For those headaches with objective neurological signs or red flag symptoms as per CG150 that require an underlying pathology to be ruled out. This would be run by a neurologist.
- Specialist Headache Clinic (16%)
A sub-clinic in general neurology, for rare and refractory headache disorders.
In short, it was predicted that only 34% of all headache referrals coming into general neurology needed to be seen in the OPD.
The proposed pathway concept was as follows:
Reasons for implementing your project
The proposed headache service was for all adults in Oxfordshire (total Ox. population 680K). Neurology activity by the NHS Trust is commissioned by the Oxfordshire CCG.
The Cost Burden of Headache
Before the new service, all adult headache referrals from GPs were seen in the General Neurology OPD, accounting for 1,100 referrals pa (30% of neurology GP referrals).
The cost-burden of headache was estimated to be £409,893 pa. This was based upon:
- a local tariff OPD of £238 (first appointment) & £136 (follow-up) and estimated follow-up rates of 98%.
- An MRI Head tariff of £124, with 24% of people seen in the OPD for headaches receiving imaging, despite migraine being overwhelmingly the most common diagnosis. Anecdotally, the most common reason for imaging was patient reassurance.
The new pathway concept offered a significant cost-savings opportunity:
- Providing advice back to the GP and patient without an appointment would save the appointment tariff.
- Imaging without appointment would cost only the MRI tariff.
- The community headache clinic could be run cheaper than a hospital OPD because of lower.
Directing 66% of all headache referrals away from the general neurology out-patient department would create 726 first appointments in extra capacity per annum for other neurological conditions, reducing the wait time for those patients.
The new pathway would also incur costs:
- Headache Consultant: to triage of referrals, order MRIs, write to patients and their GP, support the training of GPs interested in running the community clinic, and associated administrative costs. This was estimated to be £34,329 per annum based on a consultant working three programmed activities per week.
- The Community Headache Clinic: A pilot community clinic sponsored by the Thames Valley Strategic Clinical Network showed that this clinic could be run for a tariff of £110 for a first appointment, and £55 for a follow-up appointment (that is, a 41% saving on the general neurology out-patients tariff).
- An additional 10% contingency on all these costs was also factored in.
After balancing the predicted savings against the additional costs, it was estimated that the original headache burden cost of £410K could be reduced to £241K (a saving of £169K; see chart below).
How did you implement the project
NICE QS42 and CG150 emphasise the importance of a timely positive diagnosis of primary headache disorders, without the unnecessary use of imaging, so that effective treatment can be advised and the risk of medication overuse minimised.
Therefore, the purpose of the pathway was to:
- Provide headache sufferers with a rapid and accurate diagnosis.
- Provide clear and accessible management advice for patients and GPs based on CG150 as well as those of the Scottish Intercollegiate Guidelines Network, and the British Society for the Study of Headache.
GP Management Guidelines where written to be easily readable so the healthcare professional could find all the management options available in within the time-limiting confines of a primary care consultation (QS42.5):
There were a number of obstacles to overcome:
- Contracting: Who would ‘own’ the community headache clinic – the CCG or the Hospital Trust? It was decided that the Trust would own the clinic so that the GP clinicians would benefit from crown indemnity.
- The illusion of savings: There was no true ‘saving’ for the provider or commissioner because the extra capacity created by re-directing referrals away from the out-patients would simply be filled by more complex patients. This was overcome by recognising that a) neurologists preferred to see more complex conditions in their clinics; and b) the extra capacity was being created at approximately 50% of the current standard £238 hospital tariff. The pathway pilot was funded as a ‘risk-share’ with both the CCG and the Hospital Trust splitting the start-up costs of the pathway. In the future, it will move to a ‘payment by results’ tariff funding model.
- IT Infrastructure: NHSE mandates that referrals must now be made via the electronic referrals system (eRS). eRS prevents provider triage because the patient must be booked into a clinic before the provider is able to read the referral letter to triage it. The inevitable change in 66% of appointments could cause confusion and disgruntlement for patients. There are eRS systems which allow central triage of referrals prior to booking an appointment (such as the new ‘Referrals Assessment Service’) but this takes the burden of booking clinics away from the referrer/patient and to the provider – an unacceptable prospect for the NHS Trust due the additional administrative resources needed. This could not be overcome. The default eRS system had to be used.
- Special Interest GPs: It was feared that there would not be enough GPs interested in running the three weekly community headache clinics. However, this fear was not actualised.
The following data is preliminary, based on 3 months of pathway activity and 10 community clinic sessions.
The pathway has out-performed predictions. In the first three months, 89% of all headache referrals were directed away from general neurology outpatients. The community headache clinic had a very low MRI rate (2%) and follow-up rate (2%). At full roll-out this would reduce the cost of headache from £410K to £142K, and an increase in capacity of 979 first appointment per annum.
Currently, data is only available for clinical performance of the community headache clinic (n=58).
- All patients received a diagnosis for their headache (QS42.1; CG150). For 79% of patients, this was the first time they had been diagnosed (despite many suffering for a long time). 94% of patients were diagnosed with migraine. 25% of patients had medication overuse headache.
- Most of each consultation was spent making a personalised care plan, which is now also provided in writing for all patients. It specifies appropriate management of their headache (including combination therapy for migraine), and educates about the risk and management of medication overuse headache (QS42.2 & 4 & 5; CG150).
- 9% of patients receive an MRI (compared to a predicted 24%; QS42.3). Only 1 MRI was done for clinical reasons, the remainder were reassurance scans. This highlights the challenge of managing patient expectation, and patient/referrer anxiety in the context of headache. (Of note, approx. 82% of referrals to the clinic were regarding referrer anxiety rather than patient anxiety).
- Prior to their appointment, only 32% of patients felt able to manage their headache. This rose to 100% after the clinic appointment. Patient satisfaction was high:
Key learning points
- Patients feel empowered by a positive diagnosis for their primary headache disorder and a care plan that details multiple management options.
- It is possible for commissioners, secondary care providers and GPs to come together in good accord, overcome competing interests, to develop a pathway which works well for patients and reduces costs. Agree on shared objectives and underlying principles early. If one party does not like a proposal, they should propose another that meets the shared agenda.
- Estimating the disease prevalence in secondary care clinics (and their investigation and follow-up rates) is significantly hampered by a lack of out-patients coding. Services must currently rely on local audit and the sharing of that data with others.
- Triaging is best done by an experienced consultant rather than relying on referrers to choose the right service to refer into.
- Unfortunately, the current eRS system prevents central triage, as it demands that the referrer chooses which clinic to send the patient to. Given the lower diagnostic rates of referrers, it is unlikely that a supporting referral proforma would improve appropriate clinical choice of service within the headache pathway. NHSE must support secondary care providers in managing pathways which rely on central triage (such as encouraging the uptake of the Referral Assessment Service) as the clinical benefits and efficiency savings are significant.
- The main challenge for the appropriate management of headache is a diagnostic Interventions need to empower accurate diagnosis as quickly as possible so as to ensure appropriate treatment.
- Referrer anxiety is high in headache. Referrers tend to over-interpret typical features of primary headache as “red flags” needing investigation, which pushes up referral. NICE and The British Society for the Study of Headache are seeking to draw up “green flags” – features of headache that should reassure the healthcare professional that the headache is not sinister.